PATIENT HEALTH QUESTIONNAIRE

    What is your main dental need?

    Are you under a physician’s care now?

    YesNo

              If yes, please explain:

    Have you ever been hospitalized or had a major operation?

    YesNo

              If yes, please explain:

    Have you ever had a serious head or neck injury?

    YesNo

              If yes, please explain:

    Are you taking any medications, pills, or drugs?

    YesNo

              If yes, please explain:

    Do you take, or have you taken, Phen-Fen or Redux?

    YesNo

              If yes, please explain:

    Have you ever taken Fosamax, Boniva, Actonel, Zometa
    or any other medications containing bisphosphonates?

    YesNo

              If yes, please explain:

    Are you on a special diet?

    YesNo

              If yes, please explain:

    Do you use tobacco?

    YesNo

              If yes, please explain:

    Women: Are you Pregnant/Trying to get pregnant?

    YesNo

    king oral contraceptives?

    YesNo

    Nursing?

    YesNo

    Are you allergic or had a reaction to any of the following?

    Dental AnestheticsPenicillinCodeineSulfa DrugsMetalAspirinLatex

    Other :

    If yes, please explain:

    Do you use controlled substances?

    YesNo

    AIDS/HIV PositiveAlzheimer’s DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JoinAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions
    Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or seizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart Pace MakerHeart Trouble/ Disease
    HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular Heart BeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric Care
    Radiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitsTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
    Have you ever had any serious illness not listed above?

    YesNo

              If yes, please explain:

    Comments
    To the best of my knowledge, the questions on this form have been accurately answered.I understand that providing incorrect information can be dangerous to my health.
    It is my responsibility to inform the dental office of any changes in medical status.
    Print patient name _______________________________________      Signature of patient or Guardian _______________________        Date ____________________________
    Doctor Signature _________________________________________________________________________              Date ________________________________________